SCDSA Membership Application Date of Application(Required) MM slash DD slash YYYY Today’s DatePersonal InformationName(Required) First Last Home Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Cell Phone(Required)Work PhoneDate of Birth Month Day Year Department InformationPIN # Badge # Sworn Status Sworn Non-Sworn Rank / Title / Classification(Required) IE: Deputy, Sergeant, Records Officer, etc.Date of Hire(Required) Month Day Year Work Site Shift Beneficiary InformationPlease use this section to update your beneficiary.Name First Last Relationship Date of Birth Month Day Year Cell or Home PhoneAddress (Only complete if different than yours.) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Terms and ConditionsI HEREBY APPLY FOR MEMBERSHIP IN THE SACRAMENTO COUNTY DEPUTY SHERIFFS’ ASSOCIATION AND PLEDGE TO PAY DUES AS SET FORTH IN THE SCDSA BYLAWS FOR ITS MEMBERS. DUES ARE BASED UPON ½ OF 1% OF THE MONTHLY SALARY OF THE TOP STEP FOR EACH JOB CLASSIFICATION PER PAY PERIOD, UP TO A MAXIMUM OF TOP STEP DEPUTY SHERIFF. DUES ARE PAID BY PAYROLL DEDUCTION. I FURTHER AGREE TO NOTIFY THE SACRAMENTO COUNTY DEPUTY SHERIFFS’ ASSOCIATION, WITHIN TEN (10) DAYS OF ANY CHANGE IN MY STATUS. ALL MEMBERS REPRESENTED FOR WAGES ALSO PAY REPRESENTATIVE OFFICER RELEASE TIME AT A RATE OF $30.00 PER PAY PERIOD. THIS AMOUNT IS SET BY THE COLLECTIVE BARGAINING AGREEMENT TO REIMBURSE THE COUNTY FOR FULL-TIME REPRESENTATIONAL SERVICES BY THE AGENTS OF SCDSA. THE ABOVE REFERENCED DUES AND OFFICER RELEASE TIME PAYMENTS MAY BE TAX DEDUCTIBLE. ANY OTHER MISCELLANEOUS DEDUCTIONS MAY NOT BE TAX DEDUCTIBLE. I UNDERSTAND THAT A VOLUNTARY $3.80 PER PAY PERIOD DEDUCTION FOR POLITICAL ACTION PURPOSES WILL BE DEDUCTED FROM MY PAYCHECK IN ADDITION TO MY REGULAR DUES. IF I WISH TO DISCONTINUE THIS CONTRIBUTION, I WILL NOTIFY SCDSA IN WRITING. POLITICAL ACTION CONTRIBUTIONS ARE NOT TAX DEDUCTIBLE. NOTE: ON-CALL MEMBERS WILL NOT PARTICIPATE IN DEDUCTIONS FOR POLITICAL ACTION OR STAR 6 FOUNDATION UNLESS OTHERWISE ARRANGED THROUGH THE SCDSA. Terms and Conditions – Membership Application(Required) I accept the Terms and Conditions. Signature(Required)
